A recent analysis has found that more than 600,000 Americans have lost Medicaid coverage since April 1 as states resume requiring proof of continued eligibility in order to  remain on the Medicaid rolls. This massive effort to determine the eligibility of millions of Medicaid beneficiaries has been triggered by the end of the pandemic public health emergency; it’s known as the “Medicaid unwinding.” 

The analysis, conducted by KFF Health News, found that 36 percent of those recipients for whom proof of Medicaid eligibility was sought were removed from the program. Most disturbingly, roughly 80 percent of those who have been disenrolled were removed from the rolls because of technicalities such as missing paperwork or not returning a form – aka “procedural reasons.” The state never got enough information to know whether or not the individuals were eligible, and a significant number may have remained eligible but could not get through the red tape. 

The “more than 600,000” figure cited by KFF Health News is both an undercount of those who actually have been removed from the Medicaid program and a small foreshadowing of what is to come. Nineteen states began Medicaid disenrollments in April and May; KFF Health News asked all of those 19 states for statistics on the number of removals, but was only able to get data for 14 states. 

Moreover, beginning June 1, an additional 21 states plus D.C. and Puerto Rico could begin removing people from Medicaid. Those states and jurisdictions were not part of KFF’s analysis. 

Before the pandemic, states routinely monitored the Medicaid rolls to see who remained eligible and who did not. But when the pandemic hit, in exchange for providing more money to increase access to Medicaid, Congress demanded that states not drop people from the Medicaid rolls. That went on for about three years; now millions of people receiving Medicaid, many for the first time, are being asked to engage in a process they have not been exposed to in more than three years if ever: prove that they are still eligible for the program.  

The process the states are following is known as Medicaid redetermination. And many people are unaware it is even happening. 

A poll released at the end of May showed a significant number of people who unaware of the renewal process – in one state, New York, more than half of 415 respondents said they were unaware they would have to get their coverage renewed once the COVID-19 health emergency was declared over. The survey, conducted by the groups Make the Road, Center for Popular Democracy, and the People’s Action Institute, contacted Medicaid enrollees in 14 states between September 2022 and February 2023. 

The KFF analysis cited several examples of states that had huge rates of lost Medicaid coverage due to procedural issues such as missing documents or unreturned paperwork. In Indiana, KFF reported, 53,000 people lost coverage in the first month of eligibility redeterminations, 89 percent for procedural reasons. 

That led Republican state Rep. Ed Clere to express dismay over the “staggering numbers” in a Medicaid advisory group meeting. Clere questioned state officials about forms mailed to out-of-date addresses and urged them to give recipients more than two weeks’ notice before cancelling their coverage. 

Clere warned that the Medicaid disenrollments would create a catch-22: some recipients who lose coverage will no longer fill prescriptions and will cancel doctor’s appointments because they can’t afford care. Those with chronic illnesses may eventually end up in the emergency room, where they will be treated, albeit at a higher cost to the state.  

In Florida, KFF reported, nearly 250,000 people lost coverage during the first month of unwinding. Of those, 82 percent lost coverage due to procedural reasons such as incomplete paperwork. Democrats in Florida’s congressional delegation have petitioned Gov. Ron DeSantis to pause the process, but to no avail. 

In Arkansas, which also has a high disenrollment rate, advocates also have called for a pause – unsuccessfully. But there is precedent for such a move. In Idaho, state officials set a moratorium on disenrollments in April due to a technical issue. And in Iowa, state officials are holding a “safety check” to ensure that they don’t overlook any documents that have been submitted. 

Joan Alker, Director of the Center for Children and Families at Georgetown University, told The Hill that she has seen high rates of “procedural denials” in some states. 

“We’ve seen three states, at least in the first round of data, that their procedural denial rate was over 80 percent: Arkansas, Florida, and Indiana,” Alker said. “If a governor sees that high procedural denial rate, in my opinion, they should pause the process and see what is going on.” 

The Georgetown Center for Children and Families cited a Congressional Budget Office analysis that 15.5 million people would be expected to lose Medicaid benefits as a result of the unwinding, and 5 million of these would be children.  Children on the Medicaid rolls are likely to remain eligible either for Medicaid or could be transferred to CHIP, because eligibility rules allow children in households with somewhat higher incomes to qualify even if adults in those households lose eligibility. So if states are disenrolling large numbers of children, there is a good chance they are failing to help many who should continue to get free or low-cost care.  

Advocates are working with the U.S. Department of Health and Human Services’ Center for Medicare and Medicaid Services (CMS) and encouraging the agency to provide vigorous oversight over states to ensure people are not removed for technicalities. For example, they want states to use already existing data to determine eligibility – such as checking to see if recipients qualify for means-tested benefits such as SNAP or SSI. They want CMS to require states to meet a certain standard of performance for response time for people seeking to confirm their eligibility by phone – right now, reports have surfaced of people waiting hours and hours on hold. Advocates are pressing for adequate translation services. And they also want Medicaid managed care providers and community health center staff to be allowed to assist patients in filling out the forms. Most important, they want CMS to require states to place a hold on terminations if they do not meet basic standards for service. 

Some states are doing better at carrying out the redeterminations. In Pennsylvania 68 percent of those reviewed had their eligibility renewed; 18 percent were confirmed ineligible and only 14 percent were dropped for procedural reasons. In contrast, in Arkansas only 49 percent were renewed, 10 percent were confirmed ineligible and a whopping 44 percent were denied for procedural reasons. CMS should be holding all states to standards that reduce denials for incomplete paperwork. 

In one state, the Medicaid redeterminations are potentially coming into conflict with lawmakers’ decision to greatly expand the program. Earlier this spring, North Carolina became the latest state to approve Medicaid expansion, following South Dakota, where expansion takes effect July 1. But in North Carolina’s case, even though the expansion law is on the books, expansion cannot happen until the state budget is approved – which may not occur until very late this year. That means hundreds of thousands of North Carolinians may find themselves losing benefits only to regain them months later – if they know to apply. 

“There’s going to be a lot of people falling through the cracks, even in the best of situations,” David Anderson, a researcher at Duke University’s Margolis Center for Health Policy, told NC Health News. “And since we’re going to have a gap between redetermination starts and when expansion starts, it’s not the best situation.” 

Anderson said the challenge of redeterminations is made more complicated because of who Medicaid benefits. 

“Our Medicaid population, as a class, is either very old, very sick, or very poor or kids,” Anderson said. “It’s a population that historically, when they’re faced with the substantial compliance cost of filling out paperwork correctly, there’s going to be errors.”